Do the dangers of concussion among our nation’s youth outweigh the benefits of contact sports?

Those are words you don’t expect to hear coming from the
mouth of NHL bruiser-turned-broadcaster Matthew
Barnaby. Drafted by the Buffalo Sabres in 1992, the
Canadian-born right-winger was known as much for his pugilistic
style as for his stickhandling skills.

But that was a lifetime ago. It’s now March of 2013, six
years after a career-ending concussion forced Barnaby off the ice.
He’s hosting his podcast, “Gloves OFF!,” and his
guest is Elad Levy—professor of neurosurgery and
radiology at the University at Buffalo, founder of the Program for
Understanding Childhood Concussion and Stroke (PUCCS) and the
man who advised Barnaby to retire in 2007. Levy is describing the
effects of multiple concussions, like the 15 or so that Barnaby
estimates he suffered over the years.

“You can think of concussions as mini-blast
injuries,” Levy says, comparing them to the wounds caused by
battlefield explosions. He goes on to emphasize the danger of
receiving a second concussion before having fully recovered from
the first, a circumstance that can greatly amplify the damage
incurred and, in some cases, lead to permanent disability or even
death.

“So,” Barnaby asks with grim humor, “when I
returned to play after being knocked out cold during a game in
1994, that probably wasn’t a good thing?”

Concussions, concussions everywhere

Sports-related brain injuries are a hot topic these days. There
are the headline-grabbing reports of professional athletes like
Barnaby whose careers were sidelined by concussion. There is the
ever-growing list of retired football and hockey players who have
been diagnosed post-mortem (often post-suicide) with the
degenerative brain disease known as chronic traumatic encephalopathy (CTE),
allegedly brought on by repetitive head trauma. And then there are
the parents’-worst-nightmare stories, like that of Damon
Janes, the 16-year-old high school running back from Brocton, N.Y.,
who lost consciousness after an apparent helmet-to-helmet collision
during a game this past September and died in the hospital soon
afterward.

Add to all that a constant stream of new information that seems
to widen the scope of concussion risk and consequences by the day,
and it’s no wonder people are in a bit of a panic about
concussions—particularly the parents of the millions of
children and adolescents who play contact sports. In years past,
many of those concerned parents funneled their children away from
football and hockey, and into supposedly safer games like soccer
and basketball. But according to the latest statistics, those
sports are high on the list for concussion risk too. And while
tragedies like the one that befell Damon Janes are exceedingly
rare—according to a recent study in the American Journal of Sports
Medicine, an average of 12 high school and college football players
die annually, with cardiac failure the most common
cause—concussions among children are not.

The Centers for
Disease Control and Prevention (CDC) has estimated that during
the period from 2001 to 2009, emergency rooms in this country
treated more than 170,000 individuals under the age of 19 for
sports- and recreation-related traumatic brain
injuries—including concussions—with the overall rate
rising 60 percent during that period. And several studies show that
football, ice hockey, lacrosse, wrestling, soccer and basketball
lead the league in concussions for high school
athletes—concussions that can cause kids to miss school,
suffer mood swings and experience difficulty focusing and learning
new information for days, weeks or even months.

What’s a parent to do?

On a positive note, the rising youth concussion rate is at least
partially due to greater public awareness. In addition to more kids
getting the medical help they need, there are now organized efforts
to prevent and deal with sports-related youth concussions,
including laws in most states stipulating how concussions should be
managed, and rules in organizations (such as the Pac-12 collegiate
athletic conference and the Pop Warner youth football league)
limiting contact during practice. There are also several outreach
and education initiatives, like the CDC’s Heads Up program (see “Learn
More”), where there used to be none.

On the negative side, greater awareness—much of it the
result of alarming reports of depression and suicide among
professional athletes, and stories of kids “just like
ours” never returning home from a game—has come
accompanied by a heavy dose of anxiety on the part of both
sports-playing children and their parents.

Is it warranted? Yes and no. It’s worth noting that
several of the concussion experts cited in this article have
allowed their children to participate in sports that have
relatively high rates of concussion (including Levy, whose
14-year-old son plays ice hockey—the very sport Levy advised
Barnaby to quit). All attest to the benefits, physical and
otherwise, of participating in youth athletics, and none advocates
banning contact sports outright or indiscriminately prohibiting
kids from playing them.

On the other hand, experts also agree that the still-developing
brains of children and teens may be more vulnerable to concussion
than those of adults; that young brains recover more slowly from
concussion than do more mature ones; and that the estimates
regarding the occurrence of concussions among our youth are still
probably too low, with many student-athletes failing to report (or
even recognize) their injuries.

Which leads to the most anxiety-provoking factor of all: the
fact that there are so many more questions than answers. The
onslaught of media reports notwithstanding, parents are still
finding their most basic questions unanswered—questions like,
How do I recognize a concussion? How should it be treated? How
might one or more concussions affect my child down the road? And
what, exactly, is a concussion anyway?

What we know—and don’t know

Surprisingly, there is no single answer to that last question.
John Leddy (MD ’85), clinical associate
professor of orthopaedics at UB and director of the UB Sports
Medicine Concussion Management Clinic, says there is no
objective, gold-standard definition of the injury. According to
Leddy’s research partner, Barry Willer, UB professor of psychiatry and
director of research for the Concussion Clinic, the classic
description of concussion involves an altered state of
consciousness brought about by some external force, whether that be
a blow to the head or a blast from a bomb.

Picture your brain: a gelatinous mass suspended in fluid within
a hard, bony shell. When a sudden impact causes this delicate organ
to accelerate and decelerate rapidly inside its solid casing, there
are, understandably, consequences: Chemical imbalances occur, the
autonomic nervous system goes out of whack, even the filaments that
allow brain cells to communicate with one another may become
twisted. The precise mechanisms that underlie concussion have yet
to be completely understood, but Leddy and Willer have demonstrated
that patients who continue to experience concussion symptoms beyond
the standard seven- to 10-day recovery period—a condition
known as post-concussion syndrome, or PCS—have
difficulty regulating their cerebral blood flow, causing blood
pressure in the brain to rise abnormally during physical or mental
exertion.

There is no simple physiological test for concussion; even brain
scans do not reveal the injury. Rather, diagnosis is based on the
kind of trauma sustained—that is, you got hit on the
head—and on the presence of signs and symptoms, such as
headache and dizziness (see “How to Recognize a
Concussion”). Complicating matters is the fact that symptoms
can appear in different combinations and at different times during
the hours or even days following the initial injury, which
underlines the need to continue monitoring someone who has been
dinged (asking how they feel not just after they’ve been hit
but also later that day and the following few mornings) and to seek
help from a health care professional if there’s any sign of
trouble. “Keep asking, keep assessing,” advises Maegan Sady, a pediatric neuropsychologist at
National Children’s Hospital in Washington, D.C., who works
with young concussion patients.

It’s also important to keep up with the latest findings,
as concussion management has changed significantly over the past
several years. For example, parents were once advised to keep
concussed children from falling asleep for fear that they would
never wake up again. But Keith Yeates, director of pediatric psychology
and neuropsychology at Nationwide Children’s Hospital in
Columbus, Ohio, says that studies have shown that the risk of
sudden and severe deterioration while snoozing is so slim,
“it’s not worth having a kid totally befuddled the next
day because they didn’t get any sleep.”

It also was once common practice to send a kid who’d had
his or her bell rung during a game right back onto the field.
Today, however, researchers agree that returning to play before
having fully recovered from a concussion is a very bad idea. The
data suggest that an athlete who has already had one concussion is
more likely to have another, while an athlete who has had multiple
concussions in relatively quick succession is more likely to
experience prolonged effects. As a result, children should not go
back into play the same day they have suffered a concussion, nor
should they return to play until their symptoms have disappeared.
“When in doubt,” Sady says, “sit it
out.”

Return-to-play

Therapy has changed somewhat too. Physical and cognitive rest
has long been the bedrock of concussion treatment, and doctors
still recommend that patients refrain from strenuous physical and
mental activity while they heal. But that emphasis is now coupled
with an understanding that cutting kids off completely from school
and sports for an extended period can leave them feeling isolated
and depressed, and may even delay recovery. “There is growing
evidence that if they continue to do nothing,” says Sady,
“they aren’t going to get better.”

Experts now advocate for graded return-to-play protocols that ensure athletes
are neither overtaxed nor kept unnecessarily inactive. Willer and
Leddy have even developed an aerobic rehabilitation method that
uses a treadmill to gradually increase patients’ heart rates
until they can comfortably reach their maximum level of exertion.
Experts also recommend using return-to-learn guidelines to help
children and adolescents gradually resume their studies after an
initial period of rest—for example, first trying homework,
then returning to school for a few periods or a
half-day—rather than shutting them in a dark, quiet room for
a couple of weeks, as was once common, and then expecting them to
pick right back up where they left off.

As for those terrifying long-term consequences, Willer and
Yeates are careful to point out that, though studies are currently
underway, there is as yet no definitive scientific proof linking
concussion to CTE. According to Yeates (who suspects that one of
his own daughters suffered a soccer-related concussion), there is
nothing in the scientific literature that persuades him that
youngsters ought not to be allowed to play contact sports,
including football and hockey. Most kids do not in fact get
concussed, and there’s little evidence to suggest that those
who do receive one or two knocks to the head will be at substantial
risk in the long term.

Similarly, Sady and her colleagues at National Children’s
Hospital very rarely counsel student-athletes to retire from a
sport—“maybe one or two per year, out of
hundreds,” she says. Instead, they impress upon parents,
coaches, teachers and athletes the importance of learning to
recognize the signs and symptoms of concussion, seeking
professional help if they appear, and making sure that patients
avoid reinjury during the recovery period. “Parents must of
course make their own choices,” says Yeates. “But
there’s a limit to how much we can protect kids and still let
them grow up.”

Alexander Gelfand is a freelance writer based
in New York. His work has appeared in The New York Times, the
Chicago Tribune and The Economist.

How to Recognize a Concussion

Symptoms are what a patient experiences and reports; signs are
what an observer sees. Below are some of the key signs and symptoms
of concussion. If a young athlete—or anyone, for that
matter—experiences a bump or blow to the head and any of the
below signs or symptoms appear, consult a health care professional.
(More comprehensive lists are available from the sources listed in
“Learn More”)

The Safe Concussion Outcome Recovery and Education Program at
Children’s National Medical Center provides information and
services for parents, coaches and others. The program even offers a
smartphone app that helps parents and youth coaches recognize the
signs and symptoms of concussion.